Claims Examiner II (Temporary)

Job Summary

The Claims Examiner II is responsible for the accurate and timely processing of direct contract and delegated claims per regulatory and contractual guidelines, which includes:

Processing claims for all lines of business. Processing all claims type as needed. Monitoring itemized billings for excessive charges and duplications ensuring all work meets quality guidelines and is performed within acceptable time frames. Reviewing claims for required information, pending claims when necessary, maintaining a follow-up system, and updating and releasing pending claims when indicated. Meeting and exceeding performance measurements for Claim Examiners as required by the department to meet regulatory compliance. Assisting management with onsite training as needed. Assisting Claims Examiner III as needed for special requests.

Duties

Process incoming claims: Determine correct level of reimbursement based on established criteria, provider contract, participating provider group, health plan and regulatory provisions; Process all claims eligible or ineligible for payment accurately and conforming to quality, production standards and specifications in a timely manner; Document provider claims/billing forms to support payments/decisions. Negotiate reimbursement amounts for out-of-network claims; Identify dual coverage, Potential third party savings/recovery; Maintain department databases used for report production and tracking on-going work; Claims are processed within the contractual and/or regulatory time frames within or less than 45 working days and as supported by the departmental policies. (60%)

Perform special projects and ad-hoc reporting as necessary. Projects are complete and reports are generated within the specific time frame agreed upon at the time of assignment. (15%)

Assist management with in-house and on-site training as offered to employees, contracted partners and providers. (5%)

Work with internal departments to resolve issues preventing claims processing or enhancing processing capabilities. May assist in testing, changing, analyzing and reporting of specific enhancements. (5%)

Attend meetings as required. Claims Department/Operations Division is represented at internal and external meetings. (5%)

Perform other duties as assigned. (10%)

Duties Continued

Education Required

Education Preferred

Experience

Required:

At least 1 year of healthcare claims processing experience in a managed care environment.

Preferred:

Previous Medi-Cal or Medicare claims processing experience.

Skills

Required:
Ability to operate PC-based software programs or automated database management systems. 

Strong communication skills with excellent analytical and problem solving skills. 

Ability to self-manage in a fast-paced, detail-oriented environment. 

Extensive knowledge of medical terminology, standard claims forms and physician billing coding, ability to read/interpret contracts, standard reference materials (Provider Dispute Resolution (PDR), Current Procedural Terminology (CPT), International Classification of Diseases (ICD-10), and Healthcare Common Procedure Coding System (HCPCS)), and complete product and Coordination Of Benefits (COB) knowledge.

Moderate knowledge of Microsoft Word and Excel.

Preferred:

Knowledge of AB1455 regulations.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information